Professional Documents
Culture Documents
Dr. N. JAMINI
POST GRADUATE STUDENT
TRAUMATIC INJURIES
CONTENTS
1. Introduction
6. Crown Fracture
8. Root Fracture
12. Avulsion
INTRODUCTION
• Traumatic dental injuries are always caused by sudden impact force. This
impact force varies depending on the object and force.
• Trauma to the oral cavity may involve soft tissues such as lips, cheeks,
tongue and floor of the mouth and hard tissues such as teeth, jaws and
temporomandibular joints. (Cohen)
Definitions
A fracture is understood to be the cracking or breaking of a tooth that has
been subjected to a force or impact greater than its resistance (Enrique
basrani)
One important factor responsible for the loss of sound tooth structure that
is not directly associated with disease is “DENTAL TRAUMA” (Esthetics)
Anatomical Considerations
Dentoalveolar trauma involves many tissues and structures. Recognizing the
normal configuration of teeth and their supporting tissues will be helpful when
assessing the effects of trauma, planning corrective treatment and evaluating
the outcome.
A tooth consists of three hard tissues: enamel, dentin and cementum. Dentin
is formed by pulp cells and cementum is formed by periodontal ligament cells.
Embryologically, the alveolar bone is composed of the alveolar one proper
and the alveolar process. The alveolar bone proper is the compact bone within
alveolar and is formed by periotonal ligament cells.
The periodontal membrane lies between the alveolar bone and the cementum.
It is connected to the tooth and alveolar bone.
A tooth with an immature root has hertwig’s epithelial root sheath in the apical
region (Mitsuhiero Tscikibashi)
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Hertwig’s epithelial root sheath in the apical region. Hertwig’s epithelial sheath
was originally the reduced enamel epithelium separated from the enamel. The
reduced enamel is the tissue where inner and outer enamel epithelium
combine. Hertwig’s epithelial sheath plays an important role in root formation.
On the pulpal side of the Hertwig’s epithelial sheath pulpcells are induced and
differentiated to become odentoblasts, on the periodontal membrane side,
cells of the dental follicles are induced and differentiated to become
periodontal membrane cells (cementablasts, fibroblasts and osteoblasts)
CLASSIFICATION
It consist of 6 groups
a. Enamel fracture
b. Dentin fracture without pulp exposure.
c. Crown fracture with pulp exposure
d. Root fracture
e. Tooth luxation
f. Tooth intrusion
Class 1. : Fracture line does not extend below the level of the
attached gingiva.
Class 2 : Fracture line extend below the level of attached gingival but
not below the level of alveolar crest.
Class 3 : Fracture line extends below the level of the alveolar crest.
Class 4 : Fracture line within the coronal third of the root, but below
the level of the alveolar crest.
2. The absolute conviction that is impossible to view the dentin and the
pulp as separate organs and that they constitute one organ.
3. Determination of treatment.
A. Crown fractures
B. Root fractures
Class A Compromises :
All the simple enamel lesions, which involve a mesial or distal coronal angle or
only the incisal edge.
Class B compromises :
All the enamel – dentin lesions, which involve a mesial or distal coronal angle
and the incisal edge.
Subclass B
Class C compromises :
All the enamel – dentin lesions, which involve the incisal edge and at least a
third of crown.
Subclass C
Class D Compromises :
All the enamel dentin lesions, which involve a mesial or distal coronal angle
and the incisal or palaal surface, with root involvement.
Sub Class D
Etiology:
There are innumerable causes of tooth trauma and each causative factor
presents with unique circumstances.
In a prospective study where all dental injuries occurring from birth to the
age of 14 were carefully registered, it was found that 30% of children had
sustained injuries to primary dentition and 22% to the permanent dentition.
Any injury to children on the face affecting the appearance, speech and
functions causes much concern physically, physiologically and
psychologically.
More traumatized will be the parents, which at times requires more attention
than the child.
Epidemiology:
Classification:
Crown infraction
Crown fracture
Crown and root fracture
Root fracture
Concussion
Subluxation
Extrusion
Lateral luxation
Intrusion
Avulsion
Treatment:
Treatment of primary tooth trauma crown infraction and crown fractures that
do not involve the pulp
Pulp therapy and resin restorations or full coverage, stainless steel or tooth
coloured crowns.
These teeth usually extracted, but pulp therapy and full coverage is an option
in some instances.
Root fractures:
Another cause is resorbed roots. Most affected are the maxillary centrals.
Displacement like intrusions at times neglected as pain or injury or bleeding is
minimum. While examining the intruded teeth certain factors should be
considered as:
Root fractures
Alveolar bone fractures.
Relationship of the primary teeth with developing bud after the
injury.
Treatment :
Alignment
Realignment
Splinting is not advisable because of uncooperation of child
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Intrusion:
This is potentially for the primary tooth, root to be forced into the developing
permanent tooth follicle when this occurs, the primary tooth should be
extracted.
In most instances of intrusion, the apex of the primary tooth root will be forced
facial to the developing follicle & even through the facial plate of bone. This
results because of the more facial development location of the follicle & the
fact that the maxillary incisor roots have a slightly labial curvature in their
apical one third.
Extrusion:
Extruded primary tooth should be evaluated carefully, for any fracture of root
or alveolar bone.
If the tooth is missing all efforts should be made to trace it. If it could not be
traced careful examination to rule out buried tooth, swallowed tooth, aspirated
tooth or nasal intrusion.
Incase of intrusion not piercing through the vestibular bone, causes labial
displacement, in most situations further resorption take place in 6 months
time. If no reeruption extraction is indicated.
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Avulsion:
1. Replantation
2. Reaction of primary incisors to trauma
1. Colour change
2. Pulp necrosis
3. Pulp canal obliteration
4. Gingival retraction
5. Permanent displacement
6. Surface resorption
7. Ankylosis
8. Disturbed physiologic resorption
1. Enamel hypoplasia
2. Crown dilaceration
3. Root formation
4. Dome shaped teeth.
The extent of damage depends on the age of the patient, at the time of trauma
and the nature of the traumatic injury.
hypoplasia of the enamel are due to vertical force. Bending and deformity of
the crown is caused by the tooth germ being bent due to the root of the
primary tooth being pushed against the tooth germ palatally. Bending of the
root, lack of root development is caused by damage of Hertwig’s epthelial root
sheath when the entire tooth germ is pushed apically.
As discussed any injury may not be confirming to only dental or oral tissues.
Face injuries, head injuries and vital organs should be recognized and proper
reference should be made if necessary.
Complete examination
[Satish chandra]
Chief complaint, history of present injury, the medical history are required to
be elicited from the patient before commencing clinical examination. (Jacob G
Daniel)
Outline of initial neurologic assessment for the patient with traumatic dental
injuries.
Clinical Examination:
Hard tissues:
Individual cusps can be tested for underlying fracture by having the patient
bite on a fracture detector such as tooth sloth or frac-finder (Denbur)
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Radiographic examination:
1. Detection of discoloration
2. Root fractures
3. Jaw fractures
4. The size of the pulp chamber and root canal, the apical root
development, the appearance of the periodontal ligament space.
5. Resorption and calcifications.
Date of birth :
Age :
Patient’s Name :
Male Female
Date :
Present trauma :
Date :
Cause :
Place :
General findings:
Nausea Yes No
Discoloration : Yes No
Other
Radiographic findings:
Diagnosis:
Avulsion
Treatment Includes:
Treatment :
a. Sealing the exposed dentin tubules.
b. Stimulating the pulp to form a layer of reparative dentin
The remaining pulpal dentin thickness over the pulp is important in managing
this type of fracture.
Stanley observed that remaining pulpal dentin more than 2mm is sufficient for
shielding the pulp from most forms of irritation.
Ca(OH)2 paste is very effective as a stimulant for the pulp and acid – etch
composite resin is the material of choice for holding the liner in position
restoring the appearance.
a. Proper care should be taken when restoring composite resin, composite
resin should not contact the exposed dentin.
b. Dentin should not be dried.
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Treatment:
Immediate treatment increases the chances for the preservation of pulp vitality
and normal health of pulp.
1. Vital pulp therapy comprising pulp capping, partial pulpotomy and cervical
pulpotomy.
2. Pulpectomy.
Indications:
Technique:
The exposed dentin and the exposed pulp are covered with a ca (OH) 2
paste such as dycal.
The lost tooth structure is restored with acid etch composite resin.
Follow up:
Electrical pulp testing, thermal testing, palpation tests and percussion tests
should be carried out at 3 weeks, 3,6, and 12 months. A hard tissue barrier
can be visualized as early as 6 weeks post treatment.
Indications:
The zone of inflammation in the pulp has extended more than 2mm in an
apical direction.
Procedure:
Extirpation of a part of the vital pulp under anesthesia. The pulp remanent is
protected with a dressing. It is important to maintain the vitality of the healthy
pulp until apical development is complete. In this way, the normal
development of the entire length of the root will be obtained.
Indications:
Contra indications:
Clinical procedure:
a. Anesthesia
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b. Remove caries from the fracture site to avoid contamination of the pulp
tissue.
c. Isolate and apply an antiseptic.
d. Access opening. This is done according to the location of the fracture and
the pulp exposure following accepted techniques.
e. Pulpectomy : This cut is made at different heights. The greater pulpal
damage, the closer to the apex will be the level of the bipulpectomy.
There are 2 variations of the technique:
Use slow speed with a round bur of a diameter slightly larger than that of
the root canal, to avoid total removal of the pulp.
Use high speed with a carbide bur smaller than the diameter of the root
canal cooled with water and using an explorer.
f. Irrigate and dry the cavity.
g. Placement of Ca (OH)2: Ca (OH)2 paste is placed over the cavity. It is
continued by filling the rest of the cavity with ZnoE followed by Zn Po4.
h. Amalgam in posterior tooth or composite in anterior tooth.
i. Post operative radiograph.
j. Clincoradiographic recall examinations. This will serve to verify the
formation of a calcific barrier and degree of apical development.
Pulpotomy involves removal of the entire coronal pulp to the level of the root
orifices.
INDICATIONS:
TECHNIQUE:
2. The coronal pulp is removed but only to the level of the root
orifices.
3. Ca (OH)2 dressing and coronal restoration carried out.
Prognosis: 75%
Pulpectomy:
Indications:
Technique:
1. Rubber dam is applied and roof of the pulp chamber should be removed
to gain access to the root canals.
2. The contents of the pulp chamber and all debris from the occlusal third
of the canals should be removed.
Prognosis : 90%
Partial pulpectomy:
Indications:
Technique:
3. The canal is dried with paper points and a soft mix of Ca (OH) 2 spun
into the canal with a lentulo spiral instrument.
5. The Ca (OH)2 is packed against the apical soft tissue with a plugger.
6. Ca (OH)2 meticulously removed from the access cavity and well setting
temporary filling is placed in access cavity.
Classification:
1. Simple - When only one line of fracture divides the root in two portions.
2. Multiple - When the root is divided into more than two fragments.
A direction of the line of fracture with respect to the long axis of the
tooth.
Location of fracture:
1. The cervical third: The line of fracture is close to the cervical line of the
tooth.
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2. The middle third : The line of fracture approximately divides the root in
two halves.
3. The apical third : The line of fracture is in the apical portion of the root.
Horizontal fracture:
a. Patient experiences discomfort over the buccal portion of the affected tooth.
b. Tooth is sensitive to vertical and horizontal percussion.
c. Spontaneous pain present.
d. Slight or moderate mobility.
e. Patient feel that tooth may elongated.
f. Color change in crown.
g. Palpation provide information about the degree of tooth malposition
Radiographic examination:
Fracture is seen in radiographs as a dark line that extend across the root.
Treatment:
The type of emergency Treatment depends on whether the pulp remains vital.
a. Anesthesia.
b. Reduction and Repositioning of the segments, moving the coronal portion
apically using finger pressure. A radiograph should be taken to determine
the position of the segments.
c. Stabilize the tooth.
d. Examine the occlusion of the tooth.
e. Selective occlusal grinding done when necessary.
f. The splinting fixation should remain in place from 2 or 3 months.
g. Periodic recall examination of the involved tooth should be done.
1. Orthodontic wire
2. Acrylic splint
3. Orthodontic bands and brackets
4. Composite with acid etch
Orthodontic Wire:
Stainless steel wire 0.8 to 1 mm is recommended extending at least to
adjacent tooth on each side of the fractured tooth. The wire is passed from
the buccal to the palatal area of the ends are loosely adjusted on the distal of
the last tooth on the splint. To complete the fixation, small V-shaped wires is
placed from the palatal side to buccal side of each interdental space,
engaging the palatal and buccal portion of the principle arch wire.
Once this step has been done, the free ends of ‘V’ shaped wires are twisted
with a haemostat. The excessive wire is removed, leaving about 2mm of
twisted ends which are bent into each interdental space.
Acrylic Splint:
a. Direct :
1. without a brush
2. Brush on technique
b. Indirect
Direct:
This is done in mouth with self-curing acrylic. The acrylic mass is placed on
the labial aspect of the teeth and removed before it polymerizes to avoid its
retention. Check occlusion, polish and cement with ZnoE or poly carboxylate
cement. The affected tooth and at least adjacent tooth on either side of
fractured tooth is isolated and dried. Acrylic powder and liquid are applied with
a brush to labial and lingual surfaces in middle third and in inter-dental
spaces. After the material sets, it is polished with sandpaper disc. Occlusion is
checked.
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Indirect:
a. An impression is taken.
b. The area on the model is covered with wax to eliminate undercut
c. A splint is made of self-curing acrylic.
d. After polishing, the splint is cemented.
Follow-up
With vitality: Periodic clinico radiographic examination.
B. Without vitality:
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Treatment:
Clinical History:
1. Spontaneous pain.
2. Pain on mastication
3. A deep narrow pocket on lingual or buccal root surface or both surfaces.
4. A radiolucent zone from the apex to the cervical third of the root.
5. Fibro optics is useful in locating this type of injury.
6. Fractures can also be discovered when the patient bites down on an
orangewood stick.
Certain root fractures are not visible clinically nor radiographically it is
necessary to raise or flap for direct visualization and verify the existence of a
partial or total vertical fracture.
1. This type of healing appears when the trauma has occurred before the
complete development of alveolar process. This permits the coronal
segment to continue its euption and the apical segment remains included in
the bone.
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2. Bone and connective tissue are seen separating both segments. These
segments are surrounded by periodontal ligament.
3. The tooth is firm and maintains its vitality.
1. When the pulp tissue in the coronal fragment becomes necrotic or when
the line of fracture is close to the gingival sulcus, it causes contamination
and proliferation of chronic inflammatory tissue.
2. Wide radiolucent zone interposed between the segments and extending to
the alveolar bone at the level of the line of fracture.
3. On clinical examination, the tooth can have mobility, be extruded and be
sensitive to percussion.
Complications:
1. Root resorption
Root resorption caused by a change in normal function of the
periodontium. The distruction of periodontium would leave the root in
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contact with the alveolar bone. Two situations can arise from this
situations: Ankylosis of the tooth or root resorption.
2. Calcification of the pulp chamber or root canal.
3. Periodontal complications
The fracture passes through enamel, dentin and cementum without pulp
exposure.
The fracture passes througn enamel, dentin and cementum with pulp
exposure.
Treatment Procedures:
2. Local anesthesia.
5. Pulp capping: If there is slight pulp exposure, use Ca(OH)2 cement for pulp
dressing.
First, remove any pulp tissue from the pulp horn of the tooth fragment and
bevel the entire pheriphery of the fracture line of the both fragment.
Next, bevel the entire pheriphery of the fractured surface of the remaining
tooth. Fit the matrix band lightly to isolate the adhesive surface from the
exudates, then apply the etchant and bonding agent to the remaining tooth
and the tooth fragment. Apply light-curing resin to the remaining tooth and
the tooth fragment and adapt the fractured surfaces closely.Tightening the
matrix band during curing allows the tooth fragment to return to its orignal
position buccolingually & mesiodistally.
8. Followup
Lateral luxation -Teeth usually have their crown displaced lingually and are
often associated with fractures of the vestibalar part of the socket wall.
Management:
Lacerated gingiva should be readapted to the neck of the tooth and sutured.
Finally, radiographs should be taken in order to verify adequate repositioning.
Splinting: (Andreasen)
It is essential that the labial surfaces are as clean as possible when the
etching solution is applied to the incisal third of the labial surface. Thereafter,
etchant is removed with a water spray and the teeth air dried. After drying the
etched area it is important that the enamel is not contaminated with blood or
saliva during application of the splint.
The splint material (Epimine resins) is then applied to the incisal half of the
labial surfaces. During the curing phase, slight pressure on the incisal edge of
the involved teeth will maintain correct position.
Usually one or two non-injured teeth should be included in the splint on either
side of the injured teeth.
Interdental fixation:
Thin, soft stainless wires (0.2mm, 32 gauge) are used for this type of fixation.
It is important that the ligatures are applied to several adjacent teeth on both
sides of traumtized area.
Archbar:
Metal bars fitted to the dental arch and ligated to the individual teeth are
commonly used. Semicircular soft metal bar is manually shaped to fit the
dental arch.
Splinting period:
Pathology:
1. Pulp necrosis.
a. Replacement resorption
b. Inflammatory resorption
2. Pulp canal obliteraton.
3. Root resorption, external
4. Root resorption, internal
a. Internal replacement resorption
b. Internal inflammatory resorption
Pulp necrosis:
2. Pulpcanal obliteration:
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Root resorption:
External root resorption:
The damage to the periodontal structures and the pulp by luxation injuries can
result in various types of external root resorption.
Surface resorption:
The root surface shows superficial resorption lacunae repaired with new
cementum. These lacunae termed as surfaced resorption.
Self limiting and shows Spontaneous repair:
These resorption cavities are usually confined to the lateral surface of root,
but this resorption type localized to the apical area resulting in a slight
shortening of the root.
Replacement resorption:
Direct union between bone and root substance is seen, the tooth
substance being replaced by bone.
Inflammatory resorption:
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Intrusion: (Cohen)
The tooth may be pushed into socket sometimes giving the appearance that
has been avulsed.
The tooth presents with the clinical presentation of ankylosis because the
tooth is firm in the socket, gives a metallic sound to the percussion test and
after the injury is in infra occlusion.
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Examination of the floor of the nostril will reveal the protruding apex.
Radiographic findings:
Clinical Findings:
Teeth appear elongated and most often lingual deviation of the crown there is
always bleeding from the periodontal ligament.
Radiographic findings:
Management:
b. Extrusion
Reposition the tooth to normal position.
c. Intrusion:
Repositioning should be carried out orthodontically over a period of 3-4
weeks.
h. Splinting period.
Prognosis:
873.68 Avulsion:
The avulsed tooth is both a dental and an emotional problem. It is usually the
trauma to an anterior tooth of a child.
The shock and pain of the injury, the loss of a tooth needed for eating,
speaking and smiling often lead to emotional upheaval in-patient as well as
parent.
The longer the luxated tooth is out of its socket, the less likely it will remain in
a healthily functional state after replantation.
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The following instructions should be given to the parent as soon as the dentist
has been informed of the accident and in preparation for a imminent visit.
2. Have the patient rinse mouth. Replace tooth in its socket using gentle,
steady finger pressure. If the patient is cooperative and able, have the
patient gently close the teeth together to force the tooth back into its
original position.
If the patient or parent cannot replace the tooth in its socket then care in
transporting that tooth to the dentist becomes essential.
The tooth must be carried in a moist vehicle to maintain the viability of the torn
periodontal ligament. The most readily available vehicle is the patient mouth,
in which the tooth is bathed in saliva at body temperature.
If this cannot be done safely such as if the patient is too young then one
should place the tooth in a container of milk.
The tooth should not be wrapped in dry handkerchief or tissue because the
periodontal ligament will become dehydrated.
Several studies have shown that extra oral time for an avulsed tooth optimally
should not exceed 30 min and the patient must be taken to the dentist
immediately.
Extraoral time:
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Shorter the extraoral time, the better the prognosis for the replanted tooth.
Both the pulp and the periodontal ligament suffer extensive damage during an
extra-alveolar period and healing is almost entirely dependent upon the time
of an handling during the extra – alveolar period (Andreasen)
Short periods of dry storage increase both replacement and inflaminatory root
resorption.
Water:
Vestibule:
Keeps moist but is not ideal because of incompatible osmolarity, PH and the
presence.
The tooth can be stored in saliva up to 2 hours. It decreases the speed with
which periodontal ligament tissue will die.
Milk:
It has been used as a tissue culture and has demonstrated the ability to
preserve and reconstitute the cells of the periodontal ligament.
Saliva:
Disadvantage:
If child is too young, is unreliable, there is too great a chance for swallowing
the tooth on the trip to the dentist’s office
Advantage:
The importance of the medical history should not be compromised and must
be completed before local anesthetic is administered.
The case history is taken with emphasis on the time interval and condition
under which the tooth has been stored.
Determination of other injuries and the extent of bony involvement may give
the clinician as how the avulsion have occurred.
When the trauma occurred, whether the tooth was dry or wet and the storage
condition are critical in formulating a treatment plan. The place of the accident
may dramatically influence the prognosis contact with foreign material and
may alter the treatment.
Treatment:
Main aim is to replant the tooth with the maximum number of periodontal
ligament cells that has potentially to regenerate. If this is not possible steps
are taken to prepare the root to slowdown the inevitable resorption.
In Clinics:
Closed apex:
Open apex:
Rinsing and replanting at the earliest. The tooth is socked in storage media to
reduce ankylosis by socking debris and bacteria are reduced which reduces
inflammation. The doxycyline may help better.
By this time periodontal ligament cells have died. Socking will have no effect
than physically to remove debris.
• Replantation is performed
• Endodontic treatment can be preformed extra orally.
Socket Preparation:
The Socket should be left unaltered to greatest extent. If blood clot is present,
blood should be aspirated.
Replant slowly
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Suture gingival laceration, especially in the cerrical area. Verify normal position of
the replanted tooth radiographically. Apply a flexible splint for 1 week
Refer to physician to evaluate need for a tetanus booster if avulsed tooth has come
to contact with soil or tetanus coverage is uncertain.
Dignosis The Tooth has The tooth has been Extra oral dry time
clinical situation already been kept in special more than 60 min
replanted storage media .
The extra oral time
is less than 60 min
Treatment Clean affected If contaminated, Replantation is not
area with water clean the root indicated
spray, saline or surface & apical
chlorhexidine rinse. foramen with a
stream of saline
Examine the
alveolar socket. If
there is a fracture
to the socket wall,
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reposition it with a
suitable instrument.
Administer systemic antibiotics penicillin V 1000mg & 500mg 4xper day for 7 days
or for patients not susceptible to tetracycline staining. Doxycycline 2xper day for 7
days at appropriate dose for patient age & weight. Refer to physician to evaluate
need for a tetanus booster if avulsed tooth has come into contact with soil or
coverage is uncertain.
Patient Instruction
Follow-up.
Splinting:
The acid-etch composite & arch-wire splint is the most commonly used splint
for traumatic injuries.
ligaments.
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Prognosis:
1. Surface resorption
2. Replacement resorption
3. Inflammatory resorption.
Pulp Necrosis:
Injuries to teeth may be combined with fractures of the alveolar bone soft
tissues and mandible as well as soft tissues trauma to the gingiva and oral
musoca.
This fracture involves the alveolar bone coronal to the apex , usually the
fracture line passes through the alveolus.
This is an extensive fracture of the basal bone and mandibular ramus. Usually
the alveolar bone is also involved.
Treatment plan:
Resorption of the displaced teeth and alveolar bone at the same time. Use
teeth for splinting. Remove the splint 2 to 3 months later.
3. Endodontic treatment:
Traumatic teeth associated with alveolar bone fracture usually have apical
vascular disruption of the pulps. Perform endodontic treatment for pulp
necrosis so that it does not hinder fracture healing.
Abrasion:
For abrasions and contusions, only cleansing and observation are necessary
for lacerations, depending on their size and depth, suture the wounds after the
administration of local anesthetic.
FACE GUARDS:
Faceguards are usually prefabricated cage type guards that are attached to
helmets. Recently, faceguards of clear polycarbonate plastic have become
available.
Advantage:
Provide good protection to face and teeth.
Disadvantage:
Not applicable to all activities and do not protect the teeth if the individual is hit
under the chair.
MOUTH GUARDS:
Mouth guard is very effective in decreasing the severity and number of dental
injuries. There a 3 types of mouthguard in the market.
i. The stock mouth guard
ii. The mouth formed or boil and bite
mouth guard
iii. The custom-made mouth guard.
Disadvantages: